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Physical assessment skills: a developing dimension of clinical nursing practice
Original article
Physical assessment skills: a developing dimension of clinical nursing practice Maureen A. Coombs1 and Sue E. Moorse
This paper proposes that the current use of physical assessment skills within critical care nursing practice is part of a on-going nursing role development process. A review of the critical care nursing role highlights how nurses in this setting have always been responsive to patient management needs. In exploring one recent nursing role development, the critical care outreach nurse, it is suggested that enhanced assessment skills enable these practitioners to safely and competently assess critically ill patients out of the intensive care environment. The use of patient case studies in this paper, demonstrate how the theory of a more intensive physical assessment knowledge base can be applied in the everyday practice of an critical care outreach nurse. Through such systematic patient review, patient management plans can be agreed and ward based practitioners can be supported in the on-going treatment of sick ward patients. The use of the cases presented also highlights the complexity of the outreach nurse’s practice in addressing clinical management and team management issues. © 2002 Elsevier Science Ltd. All rights reserved.
Maureen A. Coombs Consultant Nurse in Critical Care, Intensive Care Unit, D Level Centre Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel: +44 23 80796116; E-mail: maureen. [email protected]. nhs.uk Sue E. Moorse Outreach Sister, Queen Alexandra Hospital, Portsmouth, UK (Requests for offprints to MAC)
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Introduction Nursing role developments across health care are currently occurring at an unprecedented rate. The opportunity for fundamental role development has been brought into sharp relief against the backdrop of professional development (United Kingdom Central Council 1992), technological progression, medical workforce (Department of Health 1993) and organisational change (Walby & Greenwall 1994). Through the recent modernisation agenda for the health service, there has been a renewed emphasis on flexible working boundaries and responsive, proactive 1
Senior Lecturer, School of Nursing and Midwifery, University of Southampton, Southampton, UK.
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health care practices (Department of Health 1999, 2000a, 2001). Such potent influences have exerted a strong affect across all clinical practice arenas, including that of critical care. This paper focuses on one developing area of practice within critical care, that of the use of physical assessment skills. Using the experiences of critical care outreach nurses, these skills are explored. The contemporary role of the critical care nurse and the development of the concept of outreach services are briefly discussed to set the scene. A historical perspective on the emergence of these predominantly medical skills into the nursing role is then explored. Following details of the specific educational preparation undertaken by the authors to ensure proficiency in this area, application of these
© 2002 Elsevier Science Ltd. All rights reserved.
Physical assessment skills: a developing dimension of clinical nursing practice
skills is explored through two case studies. The paper concludes with consideration of such role development on the broader aspects of the delivery of comprehensive critical care services.
The developing role of the critical care nurse Intensive care as a clinical speciality has evolved as advances in technology and the ability of medicine to treat and support disease has occurred. Thirty years ago the different practices of medicine and nursing were easily identifiable (Roth & Daze 1984). This distinction was based on the intensive care nurse delivering treatments as ordered by the medical team. Making a differential diagnosis and prescribing was the sole domain of medicine. The contemporary role of the intensive care nurse has since developed with the addition of tasks from medicine (role extension) and the development of the nursing role (role expansion) through enhanced nursing knowledge (Hunt & Wainwright 1994). The boundary between contemporary nursing and medicine is now arguably unclear (Webb 1996). To explore such nursing role developments and nurse-led clinical decision making in intensive care, the Royal College of Nursing (1997) undertook a telephone survey of 89 intensive care units (ICUs). The qualitative component of the results demonstrated that the intensive care nurses surveyed were experiencing considerable role change. The key driving forces for this were identified to originate from within the nursing profession, and be driven by external forces e.g. junior doctors hours (National Health Service Executive 1991). However, the intensive care nurses were noted to be ‘equal to the challenge of a more advanced medical and technological care whilst retaining a strong sense of the value of nursing to patients and families’ (Royal College of Nursing 1997, p. 9).
The critical care outreach service Expansion of nursing roles and nurses undertaking clinical decision-making has been further increased with the advent of critical care outreach services. Following a review of adult critical care services, the Department of
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Health (2000b) recommended that all acute care trusts should develop critical care outreach. The three main purposes of this service are to: • Avert admissions by identifying and treating deteriorating patients in a timely manner; • Enable discharges through continued support following discharge from critical care to ward areas; • Share critical care skills through formal and informal education and support. A variety of outreach models have emerged ranging from nurses working in isolation through to multi-disciplinary teams. Many critical care outreach services have evolved from critical care units and are nurse-led. This has exposed critical care nurses to managing familiar patient problems but in new clinical settings and in contact with new clinical teams. This has resulted in critical care nurses being exposed to unfamiliar environments where there is a lack of familiar intensive patient monitoring and the absence of the immediate medical support that nurses in critical care have traditionally become accustomed to. The critical care outreach nurse is therefore often involved in the initial assessment and management of complex clinical situations. This necessitates that the outreach nurse has well-developed patient assessment skills, can make a professional judgement on the necessary action, and articulate a competent case for the course suggested. As a result of the challenges in performing safely and effectively in an outreach capacity, the outreach teams at Southampton University Hospitals Trust and Portsmouth NHS Hospitals have undertaken an introductory course to physical assessment skills.
Physical assessment skills As Rushforth et al. (1998) emphasise, within a United Kingdom context, physical assessment undertaken by nurses has historically been regarded as the recording of key vital signs including temperature, heart rate, blood pressure, and respiratory rate. Wider consultation of the North American literature reveals a broader definition in use including the auscultation of lungs and heart and palpation of the abdomen. Indeed, physical
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Table 1 Key physical assessment skills (adapted Jarvis 2000) Inspection Palpation Percussion Auscultation
Use of visual skills to gather information on a particular system, or the patient as a whole Application of touch to assess texture, temperature, moisture, organ location and size, swelling, vibration, pulsation, rigidity/spastisity, crepitation, masses and pain Taping of the skin with short, sharp strokes to assess underlying structures. Reflected sound depicts location, size and density of underlying organs Using the stethoscope to listen to sounds produced by the body
assessment skills have been located in the American and Canadian nursing syllabi since the 1970s (Bear 1995) with similar programmes more recently established within Australia (Wilson & Lillibridge 1995). Physical assessment has been defined as a systematic use of the skills of inspection, palpation, auscultation, and percussion (Bickley & Hoekelman 1999). Table 1 defines these key skill areas further. However, as highlighted by James and Reaby (1987), these skills are primarily confined within the practice of nursing to the recognition of ‘normal’ and deviations from this. The findings of empirical work undertaken in this area confirms that after completion of a physical assessment course, such skills are integrated into clinical practice (Sony 1992; Reaby & James 1990) with increased confidence in their use (Brown et al. 1987). Whilst the overall effect on patient management has not been explored, there has been a demonstrable improvement in decision making (Reaby 1990). However, caution must be exercised as much of the literature in this area uses small sample sizes and originates from North America and specifically focuses on nurse practitioner roles. These factors must be acknowledged when considering the transferability of the results.
The ‘introduction to physical assessment and history taking’ course The module that both authors undertook was offered by the School of Nursing and Midwifery at the University of Southampton. The course was offered as a 20 Credit Level 2 or 3 course comprising of 30 h of programmed study, 70 h independent study and 100 h practice. The module’s aim was to equip practitioners with an enhanced range of history taking and physical assessment skills. The
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systematic framework of inspection, palpation, percussion and auscultation was taught and then built into a more comprehensive patient assessment. The summative assessment for the module was through an OSCE (objective structured clinical evaluation) to assess practice, and a 2000 word assignment for those undertaking the module at Level 3. The module was offered to practitioners caring for patients/clients across the life span and in diverse clinical settings. In this way, the course cohort could consist of nurses working in acute medical admissions units, children’s recovery areas, mental health settings and community practitioners. The competencies gained during the module were not specifically related to patient diagnosis, but to detect normal from abnormal, thereby enhancing early detection and referral to appropriately skilled practitioners. The course was taught using a systems approach and underpinned by the theory base of applied anatomy and knowledge of key assessment techniques. Throughout the course a holistic perspective acknowledging wider psychological, emotional, and social influences was re-enforced. Patient privacy, dignity, confidentiality was also strongly emphasised through sessions on the legal, ethical and documentary aspects of patient assessment and history taking. The course was run over a 12-week period allowing application in practice and shared learning in groups sessions organised by the cohort between the formal taught sessions. The practical sessions required high tutor–student ratio. This ensured that students could work in small groups with tutors to have intensive support and coaching required to become proficient in the assessment techniques. These groups also needed sensitive handling to ensure students felt comfortable to act as models for each other to allow learning to occur on healthy volunteers. Being examined by
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Physical assessment skills: a developing dimension of clinical nursing practice
ones peers for this course was a salient lesson for all in reminding us of the embarrassment patients must feel sitting semi-naked awaiting examination by a clinician.
Patient case studies As the focus of this paper is on physical assessment skills, two case studies will now be presented to demonstrate the application of physical assessment skills into the critical care outreach practice. The two case studies chosen reflect not only two of the most common patient problems encountered by the authors within their outreach role but also focuses on the examination of two different anatomical systems and the resultant assessment techniques. In this section, the patient histories are introduced followed by specific details of the physical assessment undertaken. The rationale for the clinical decisions made are then explored. These case studies are not intended to reflect a comprehensive patient assessment. Therefore, whilst a wide range of clinical diagnostic tests were also used to successfully manage these patient situations, only the pertinent clinical assessment details will be referred to. Case presentation A Peter Brown aged 54, was an emergency admission to hospital with a 3 week history of lower abdominal pain, per rectum bleeding, anorexia and weight loss. He had previously been fit and well, with no relevant past medical history. He is a non-smoker. His social history is that of a postman who lives with his wife. Five days after admission, Mr Brown developed a strangulated right femoral hernia that was surgically reduced. Post-operatively he returned to the ward but within 2 days had developed an acute abdomen. An emergency laparotomy, total colectomy and end ileostomy was performed for a colitic colon with multiple perforations. Following this procedure Mr Brown was admitted to the ICU for management of intra-abdominal sepsis. His condition improved and within 24 h was successfully weaned from the ventilator and extubated. Due to a coagulopathy, an epidural
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had not been sited and he was discharged from ICU at 18:30 h with a morphine patient controlled analgesia (PCA) pump in situ. An outreach follow-up visit that night identified that Mr Brown had abdominal pain and did not appear to be using the PCA effectively. He was shown how to use the pump again and the nursing staff were advised to contact the surgical team for alternative or supplemental analgesia if his pain remained a problem. At 07:45 h the following morning Mr Brown was reviewed again by the outreach team. An update was obtained from the ward nurse caring for him on his condition. The nurse reported that his arterial oxygen saturations had dropped to 84% on 40% humidified oxygen so he had been commenced on 100% oxygen via a non-rebreathe mask. Patient assessment On approaching Mr Brown, I established that he was lying semi-recumbent, looked pale, appeared drowsy and had an oxygen non-rebreathe mask in situ. Mr Brown was responsive to voice but appeared confused and disorientated. When attempting to sit him up he complained of severe abdominal pain. Analgesia was given by encouraging the patient to use the PCA, he was then repositioned and supported with pillows. Having gained consent, a physical assessment was performed. The results of this are detailed in Fig. 1. Interpreting the physical assessment results On reviewing the results of the physical assessment, the findings indicated that Mr Brown was in respiratory distress/failure. Respiratory failure post operatively is noted to due to aspiration, bronchospasm, atelectasis, pneumonia, pulmonary embolus or pneumothorax (Yentis et al. 2000). Other causes may include cardiac failure or fluid overload (Burkitt & Quick 2000). His discharge handover from ICU and medical notes confirmed that he had been unwell and relatively immobile since his initial surgery 5 days previously. Following his second operation he had required intubation
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Fig. 1 Findings of Mr Brown’s physical assessment.
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Physical assessment skills: a developing dimension of clinical nursing practice
and ventilation. Pain management had been problematic contributing to his inability to cough and deep breathe effectively. This can precipitate the risk of acquiring chest infection or atelectasis (Manley & Bellman 2000). On inspection, although Mr Brown was pale and perspiring, there were no signs of central cyanosis. This is normally evident when the arterial oxygen saturation is less than 85% (Smith 2000). There were no signs of chronic respiratory problems with no evidence of clubbing and a normal antero-posterior chest diameter ratio. The presence of tachypnoea, hyponoea, the use of accessory muscles and the inability to complete full sentences all indicated a compensatory increase in breathing that occur in moderate to severe respiratory failure (Mangione 2000). The irregular nature of Mr Brown’s respiratory pattern together with the asymmetrical movement of the left side of his chest was indicative of atelectasic collapse, pneumonia or pneumothorax (Jarvis 2000). On palpation there were no signs of chest tenderness or surgical emphysema. Palpation did further confirm the lag noted earlier on the left side of the chest wall. Vocal tactile fremitus was decreased in the left lung. This demonstrated that there was an obstruction in the transmission of vibrations generated by the larynx through the tracheobronchial tree to the chest wall. The causes of this include obstruction of the bronchus with a mucous plug leading to atelectasis, and fluid or air in the pleural space (Mangione 2000). Despite the above findings, assessment of the trachea was unremarkable, and the trachea was in a midline position. However as Smith (2000) suggests, in severe atelectasis there may be tracheal alignment towards the affected side. Further abnormalities to the left lung were identified through percussion. The right lung was predominately resonant. The left lung was dull to percussion as evidenced in both collapse and consolidation. There was no evidence of hyper-resonance indicative of a pneumothorax. Evidence of a collapsed lung was further increased on auscultation. In the right lung, normal vesicular breath sounds could be identified with crackles in the right base clearing with coughing and therefore suggestive of secretions. Breath sounds to the left lung were severely diminished with no
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adventitious sounds. There was no evidence of bronchial breathing that may have been heard if consolidation due to pneumonia was present (Jarvis 2000). Further assessment suggested that fluid overload was not a causative factor of his respiratory distress. Although tachycardic with a reduced blood pressure, Mr Brown’s tongue was dry and coated, his capillary refill slightly prolonged, CVP + 10 cm H20 and his urine output adequate but concentrated in appearance. Normal S1 and S2 heart sounds were identified but there was no evidence of S3 or S4 as heard in volume overload or decreased cardiac compliance. Compounded by severe pain and the ineffective use of the PCA, Mr Brown was unable to deep breathe, cough or move effectively. These factors placed him at an increased risk of developing atelectasis (Manley & Bellman 2000), which Dunn (1998) has noted to usually occur within 48 h of surgery. The conclusion from the respiratory assessment was therefore highly suspicious that his respiratory inadequacy was due to a collapsed left lung and atelectasis. Outcome for the patient Mr Brown’s management was discussed with the surgical, nursing, physiotherapy and pain teams. A chest X-ray confirmed a collapse of the left lung. Arterial blood gases were within normal limits on 100% oxygen. Alternative analgesia was prescribed by the surgical team and administered with effect. Physiotherapy management consisted of regular chest physiotherapy, saline nebulisers and Bird therapy. Intravenous fluids were increased to aid hydration. Advice was given to nursing staff regarding positioning of the patient, the need for regular deep breathing exercises, maintenance of adequate pain control and the need for regular observations, including continuous arterial oxygen saturation monitoring. Following increased pain relief and intensive physiotherapy, Mr Brown’s condition had improved by that evening. His respiratory rate was 17 breaths per min, oxygen saturations were 96–98% on 60% humidified oxygen and chest expansion and air entry on
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the left side had improved. Mr Brown was able to deep breathe and cough effectively with encouragement. Mr Brown’s recovery was slow and he remained hospitalised for a further 3 weeks. A total of 15 outreach visits were required. Once discharged home he continued to progress and at his outpatient’s appointment 2 months later, was fit and well.
explaining why I was there, I held her hand. I noted her to be cool peripherally. On asking how she was feeling in herself, she was almost euphoric and said that she had never felt better and had no pain. However she felt very thirsty. After asking Mrs Smith’s consent to examine her, she laid comfortably in the bed. The relevant assessment details are listed in Fig. 2. Interpreting the physical assessment results
Case presentation B Gladys Smith, aged 78, was initially admitted to the hospital as an elective admission suffering from gallstones. She was an active, independent, widowed lady with a close family who lived nearby. Mrs Smith was booked in for a laparoscopic cholecystectomy. Her surgery went ahead with no other past medical history except a note of atrial fibrillation that was well-controlled on oral digoxin. The surgery was documented as uneventful. However, her post-operative progress was slow and after further complaints of abdominal pain and discomfort, Mrs Smith returned to theatre during her fifth post-operative day for a laparotomy and repair of small bowel fistula. The nursing staff called the outreach team at 20:00 h the day following her small bowel fistula repair. They were concerned that Mrs Smith’s urine output had been ‘poor all day’ and her blood pressure was low (90 systolic) despite a 250 ml bolus of Gelofusine that had been administered that afternoon. It was reported that Mrs Smith had an epidural in situ and that an anaesthetist had administered a ‘bolus’ from her epidural syringe 2 h previously. The nursing staff had contacted the senior house officer who was busy in the Emergency Department and had given a verbal order for 20 mg of intravenous Frusemide. The ward staff were asking the outreach team for support as they were ‘unhappy’ with the order for diuretic but felt unable to challenge it. Patient assessment After talking with the ward nurse to clarify how outreach could help with this situation, I went with the ward nurse to examine Mrs Smith. On approaching Mrs Smith, she was sleeping but rousable. When introducing myself and
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In reviewing the key results of the physical assessment, the findings indicated that Mrs Smith was hypovolaemic. There could have been several causative factors for this. Many patients presenting with acute illness or for emergency surgery have a degree of hypovolaemia (Yentis et al. 2000). This may result from a reduction in extracellular and/or intracellular fluid as a result of dehydration, third space losses (e.g. surgery) or evaporative losses (e.g. peri-operatively), or from relative hypovolaemia due to epidural analgesia being administered. As Mrs Smith was sleepy, a substantial degree of her medical history was elicited from the nursing staff and medical notes. These revealed that due to the course of Mrs Smith’s problems and her two visits to theatre, there was an indication that she could be dehydrated. In addition, the nurse reported that she had recently received a top-up of her epidural analgesia from the anaesthetic staff. This can cause hypotension, which can be exacerbated in the presence of existing hypovolaemia (Stillwell 1996). It was clear that there had not been any excessive fluid losses from the surgical wounds or from the naso-gatric tube. However, the nature of the bowel sounds indicated a high suspicion of paralytic ileus (Metheny 1987), understandable considering Mrs Smith’s clinical history and treatment. However, this could have caused further third-space fluid shifts. Loss of blood during or after surgery was not indicated due to normal haemoglobin result. Mrs Smith’s assessment demonstrated that there was a reduction in cardiac output. Using standard nursing observations this was clearly illustrated. Mrs Smith was hypotensive at 85/40 mmHg. The medical notes revealed that previous blood pressure measurements were
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Physical assessment skills: a developing dimension of clinical nursing practice
Fig. 2 Findings of Mrs Smith’s physical assessment.
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165/115. Evidence of reduced cardiac function was further indicated by her cool and dusky peripheries and prolonged capillary refill. The poor volume radial pulse is also indicative of decreased stroke volumes. Mrs Smith had a low jugular venous pressure (JVP). Whilst acknowledging that technically ‘pressure’ can only be read with an invasive monitoring device, the term JVP is used here to indicate the height of the visualised pulsation or waveform of the jugular venous pulse. At 45◦ the JVP was not observable. It was only on posturing Mrs Smith at an angle of 30◦ that a JVP of 4 cm was observable. Mangione (2000) has observed that in patients with very low JVP the normal reading taken with the patient at a 45◦ angle may not distend the veins sufficiently to yield a reading. This was the clinical situation with Mrs Smith. It was only in reclining Mrs Smith to a 30◦ angle that the JVP became visible. Inspection of the waveform of the JVP was aided by the use of tangential lighting. This was achieved by shining a bedside light at an angle over Mrs Smith’s neck. Inspection of the JVP waveform by an experienced clinician would have revealed an absent A wave. The A wave is the first and dominant positive wave and is produced by right atrial contraction. However, inspection of the 12 lead electrocardiogram and the prescience of an irregularly irregular radial pulse confirmed that Mrs Smith was in atrial fibrillation. The decreased JVP therefore reflected a low CVP which itself is indicative of depleted intravascular volume and was confirmed by the presence of a dry, coated tongue and a reduction in skin turgour. The reduced urine output (less than 0.5 ml/kg/h) testified that there was an inadequate blood flow to perfuse the vital organs of the kidneys. The conclusion of the cardiovascular assessment was that, apart from her atrial fibrillation, Mrs Smith had no indication of cardiac disease. The absence of xanthelasmas, a yellow lipid plaque on the eyelids, indicated that there was no obvious evidence of hyperlipidaemia with its predisposition to atherosclerosis. Neither clubbing of the fingers nor peripheral oedema was present. The presence of arcus senilis, a whitish opaque ring surrounding the iris is a normal finding in
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the elderly, and therefore not itself indicative of a cardiac problem. There were no apical heave or thrills palpated, indicating that fluid overload in the left ventricle or major vessels were not present. Auscultating the heart with the diaphragm of the stethoscope, revealed that Mrs Smith had normal S1 and S2 heart sounds. The bell was used to pick up any lower pitched heart sounds including the sounds of S3 and S4. There were no added heart sounds or cardiac murmurs on auscultation. If an S3 had been heard, this would have indicated decreased myocardial contractility, myocardial failure or volume overload of a ventricle. An S4 heard would indicate decreased compliance of the ventricular myocardium (Bickley & Hoekelman 1999). The concerns regarding fluid overload were further diminished through using respiratory assessment. Mrs Smith’s respiratory rate was only 10/min, although it was acknowledged that with such a high epidural block (at nipple level) some respiratory depression may have been present. However, Mrs Smith was not using her intercostal or sternomastoid accessory muscles to breathe. The lung fields were resonant on percussion demonstrating normal aerated lung tissue (Bickley & Hoekelman 1999). Vesicular sounds were heard over all zones of Mrs Smith’s lungs indicating normal breath sounds. The only adventitious or added breath sounds were crackles heard at the lung bases. However, these were present in the dependent portions of the lungs, and cleared after coughing. This was suggestive of being caused by secretions and therefore was to be expected after a prolonged period of recumbency. Despite being in a positive 3 l fluid balance over the past 48 h, concern over her age, and a history of atrial fibrillation, it was clear that in the absence of assessment data indicating cardiac failure, Mrs Smith was therefore hypovolaemic. Outcome for the patient Mrs Smith’s continuing management was discussed with both medical and nursing staff on the ward. The key management areas reviewed were related to fluid and pain
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Physical assessment skills: a developing dimension of clinical nursing practice
management, education on monitoring the patient in atrial fibrillation, the need for epidural observations, and the encouragement of posturing and deep breathing exercises. Two hours after receiving 250 ml of Gelofusin and an increase in her hourly fluids, Mrs Smith condition had stabilised. Continuing on the oxygen, her respiratory rate was 17/min with good respiratory effort and ability to deep breathe and cough. Chest auscultation remained clear with normal vesicular sounds. Her blood pressure was maintained at 135/85 with a heart rate of 89/min. She remained in atrial fibrillation. Her urine output increased to 50 ml/h. Mrs Smith was alert and oriented in herself. She had a Glasgow coma scale rating of 15 and was painfree. Her epidural remained at 6 ml/h with a satisfactory level of block. After several further visits requiring no direct intervention from outreach Mrs Smith was discharged from outreach care and continued to have an uneventful recovery. She was discharged 2 weeks after emergency surgery to a convalescence ward in a local hospital where her family continued to visit her.
Clinical issues raised The clinical problems explored in these case studies not only demonstrate how physical assessment skills can be used by the outreach team to support patient management, but also reveal the complex ward situations that are encountered. This indicates that there continues to be organisational issues in managing medical workload, medical and nursing team working within both ward and critical care areas. As highlighted by the first case study, there is a need for ICU to ensure pain relief is effectively established prior to transfer and that both patients and staff are familiar with the pain relief methods being used. This case also enforces the need for timely and accurate performance of ward observations and the importance of action on abnormal recordings. As evidenced by the second case presented, an epidural bolus was given to an already hypotensive patient. There is therefore also a need for outreach teams to challenge our intensive care colleagues about safe clinical practices.
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The two cases presented highlight how outreach have an ICU follow-up role and provide support for the sick ward patient. In both situations, the need to be proactive in patient care is clear. This requires all to be prepared to work within clinical teams and address issues in patient management; all must take responsibility in resolving patient management issues. The outreach role is therefore not just confined to patient management issues but also support all ward based practitioners in caring for the sick ward patient. Finally, it is equally imperative that in this new area of critical care practice, outreach nurses can identify the limits of their own safe practice and know when to safely intervene, and when to seek the expert advice and assistance of other clinical colleagues.
Conclusion Nursing has been challenged to respond and adapt to the current health care changes. This can only be achieved if nursing practice is further developed to meet a patient needs-led service (Department of Health 1999, 2000a, 2000b, 2001). It is clear that new skills and knowledge will need to be embraced by nurses to respond pro-actively to such a changing culture. It is not the first time in nursing’s history that the acquisition of new skills has been called for. The undertaking of cardiac monitoring and starting intravenous infusions has been shown to dramatically change the shape of nursing practice (Shortridge et al. 1977). Critical care nurses are once again being asked to consider changes in nursing practice to ensure that patient care is delivered in a safe and timely way (Department of Health 2001). It has been argued that teaching nurses physical assessment skills can make a significant contribution to the quality of care delivery (Rushforth et al. 1998) and develop a stronger sense of collegiality with other clinicians (Brown et al. 1987). With nurses perceived as a surveillance system for early detection of adverse occurrences (Fontaine 2001), physical assessment skills can enable a more accurate appraisal of patient change (Bear 1995) and thereby improve the patient experience during their critical illness.
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The central tenet of any role development, such as the use of physical assessment skills, is the need to deliver a non-fragmented patient-focused service. However, the most profound challenge rests with the nursing profession in its ability to determine role boundaries to benefit and safeguard the patient, but without a fundamental shift in the nature of nursing. It is the clarification and re-definition of the position of nursing in using such physical assessment skills that may be most crucial. References Bear EM 1995 Advanced practice nurses: how did we get here anyway? Advanced Practice Nursing Quarterly 1(11): 10–14 Bickley LS, Hoekelman RA 1999 Physical Examination and History Taking, 7th ed. Lippincott, Philadelphia Brown MC, Brown JD, Bayer MM 1987 Changing nursing practice through continuing education in physical assessment: perceived barriers to implementation. Journal of Continuing Education in Nursing 18(4): 111–115 Burkitt H, Quick C 2000 Essential Surgery: Problems, Diagnosis and Management, 3rd ed. Churchill Livingstone, Edinburgh Department of Health 1993 Hospital Doctors: Training for the Future. Report on the working group of specialist medical training. Department of Health, London Department of Health 1999 Making a Difference. Strengthening the Nursing, Midwives and Health Visitors Contribution to Health and Health Care. Department of Health, London Department of Health 2000a The NHS Plan. Department of Health, London Department of Health 2000b Comprehensive Critical Care Review: A Review of Adult Critical Care Services. Department of Health, London Department of Health 2001 The Nursing Contribution to the Provision of Comprehensive Critical Care for Adults: A Strategic Programme of Action. Department of Health, London Dunn DC 1998 Dunn’s Surgical Diagnosis and Management. A Guide to General Surgical Care, 3rd ed. Blackwell Science, Oxford Fontaine D 2001 World shortage hits critical care. UKCC— News Tuesday, 30 October, 2001, www.ukcc.org.uk Hunt G, Wainwright P 1994 Expanding the Role of the Nurse: The Scope of Professional Practice. Blackwell Scientific, Oxford James J, Reaby L 1987 Physical assessment skills for RNs. Australia Nursing Journal 17(1): 39–41
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Jarvis C 2000 Physical Examination and Health Assessment, 3rd ed. Saunders, Philadelphia Mangione S 2000 Physical Diagnosis Secrets. Hanley and Belfus Inc., Philadelphia Manley K, Bellman L 2000 Surgical Nursing Advancing Practice. Churchill Livingstone, London Metheny NM 1987 Fluid and Electrolyte Balance. Nursing Considerations. Lippincott, Philadelphia National Health Service Executive 1991 Junior Doctors: The New Deal. Making the Best Use of Skills of Nurses and Midwives. Department of Health, London Reaby LL 1990 The effectiveness of health education programmes to teach Australian nurses comprehensive assessment skills. Nurse Education To-day 10(3): 206–214 Reaby L, James J 1990 Continuing education on physical assessment: a pilot study. Australian Journal of Advanced Nursing 7(3): 44–51 Roth MD, Daze AM 1984 Are nurses practising medicine in the intensive care unit? Dimensions of Critical Care Nursing 3(4): 230–237 Royal College of Nursing Critical Care Forum 1997 The Nature of Intensive Care Nursing Work in Intensive Care. Royal College of Nursing, London Rushforth H, Warner J, Burge D, Glasper EA 1998 Nursing physical assessment: implications for practice. British Journal of Nursing 7(16): 965–970 Shortridge L, Habiff L, Smith M, Starke A 1977 Opportunity to learn physical assessment in a continuing education course. The Journal of Continuing Education in Nursing 8(1): 6–11 Smith G 2000 ALERT A Multi Professional Course in Care of the Acutely Ill Patient. University of Portsmouth, Portsmouth Sony SD 1992 Baccalaureate nursing graduates perceptions of the barriers to use of patient assessment skills in the clinical setting. Journal of Continuing Education in Nursing 23(2): 83–87 Stillwell SB 1996 Mosby’s Critical Care Nursing Reference, 2nd ed. Mosby, St. Louis United Kingdom Central Council for Nursing, Midwifery and Health Visiting 1992 The Scope of Professional Practice. UKCC, London Walby S, Greenwall J 1994 Medicine and Nursing in a Changing Health Service. Sage, London Webb AR. 1996 Medical staffing and training. In: Tinker J, Browne D, Sibbald WJ (eds) Critical Care Standards Audit and Ethics. Arnold Press, New York, Chap. 13, pp 193–196 Wilson M, Lillibridge J 1995 Health assessment: a study of registered nurses knowledge and skill level. Contemporary Nurse 4(3): 116–122 Yentis SM, Hirsch NP, Smith GB 2000 Anaesthesia and Intensive Care A-Z. An Encyclopaedia of Principles and Practice, 2nd ed. Butterworth Heinemann, Oxford
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Physical assessment skills: a developing dimension of clinical nursing practice Maureen A. Coombs1 and Sue E. Moorse
This paper proposes that the current use of physical assessment skills within critical care nursing practice is part of a on-going nursing role development process. A review of the critical care nursing role highlights how nurses in this setting have always been responsive to patient management needs. In exploring one recent nursing role development, the critical care outreach nurse, it is suggested that enhanced assessment skills enable these practitioners to safely and competently assess critically ill patients out of the intensive care environment. The use of patient case studies in this paper, demonstrate how the theory of a more intensive physical assessment knowledge base can be applied in the everyday practice of an critical care outreach nurse. Through such systematic patient review, patient management plans can be agreed and ward based practitioners can be supported in the on-going treatment of sick ward patients. The use of the cases presented also highlights the complexity of the outreach nurse’s practice in addressing clinical management and team management issues. © 2002 Elsevier Science Ltd. All rights reserved.
Maureen A. Coombs Consultant Nurse in Critical Care, Intensive Care Unit, D Level Centre Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. Tel: +44 23 80796116; E-mail: maureen. [email protected]. nhs.uk Sue E. Moorse Outreach Sister, Queen Alexandra Hospital, Portsmouth, UK (Requests for offprints to MAC)
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Introduction Nursing role developments across health care are currently occurring at an unprecedented rate. The opportunity for fundamental role development has been brought into sharp relief against the backdrop of professional development (United Kingdom Central Council 1992), technological progression, medical workforce (Department of Health 1993) and organisational change (Walby & Greenwall 1994). Through the recent modernisation agenda for the health service, there has been a renewed emphasis on flexible working boundaries and responsive, proactive 1
Senior Lecturer, School of Nursing and Midwifery, University of Southampton, Southampton, UK.
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health care practices (Department of Health 1999, 2000a, 2001). Such potent influences have exerted a strong affect across all clinical practice arenas, including that of critical care. This paper focuses on one developing area of practice within critical care, that of the use of physical assessment skills. Using the experiences of critical care outreach nurses, these skills are explored. The contemporary role of the critical care nurse and the development of the concept of outreach services are briefly discussed to set the scene. A historical perspective on the emergence of these predominantly medical skills into the nursing role is then explored. Following details of the specific educational preparation undertaken by the authors to ensure proficiency in this area, application of these
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Physical assessment skills: a developing dimension of clinical nursing practice
skills is explored through two case studies. The paper concludes with consideration of such role development on the broader aspects of the delivery of comprehensive critical care services.
The developing role of the critical care nurse Intensive care as a clinical speciality has evolved as advances in technology and the ability of medicine to treat and support disease has occurred. Thirty years ago the different practices of medicine and nursing were easily identifiable (Roth & Daze 1984). This distinction was based on the intensive care nurse delivering treatments as ordered by the medical team. Making a differential diagnosis and prescribing was the sole domain of medicine. The contemporary role of the intensive care nurse has since developed with the addition of tasks from medicine (role extension) and the development of the nursing role (role expansion) through enhanced nursing knowledge (Hunt & Wainwright 1994). The boundary between contemporary nursing and medicine is now arguably unclear (Webb 1996). To explore such nursing role developments and nurse-led clinical decision making in intensive care, the Royal College of Nursing (1997) undertook a telephone survey of 89 intensive care units (ICUs). The qualitative component of the results demonstrated that the intensive care nurses surveyed were experiencing considerable role change. The key driving forces for this were identified to originate from within the nursing profession, and be driven by external forces e.g. junior doctors hours (National Health Service Executive 1991). However, the intensive care nurses were noted to be ‘equal to the challenge of a more advanced medical and technological care whilst retaining a strong sense of the value of nursing to patients and families’ (Royal College of Nursing 1997, p. 9).
The critical care outreach service Expansion of nursing roles and nurses undertaking clinical decision-making has been further increased with the advent of critical care outreach services. Following a review of adult critical care services, the Department of
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Health (2000b) recommended that all acute care trusts should develop critical care outreach. The three main purposes of this service are to: • Avert admissions by identifying and treating deteriorating patients in a timely manner; • Enable discharges through continued support following discharge from critical care to ward areas; • Share critical care skills through formal and informal education and support. A variety of outreach models have emerged ranging from nurses working in isolation through to multi-disciplinary teams. Many critical care outreach services have evolved from critical care units and are nurse-led. This has exposed critical care nurses to managing familiar patient problems but in new clinical settings and in contact with new clinical teams. This has resulted in critical care nurses being exposed to unfamiliar environments where there is a lack of familiar intensive patient monitoring and the absence of the immediate medical support that nurses in critical care have traditionally become accustomed to. The critical care outreach nurse is therefore often involved in the initial assessment and management of complex clinical situations. This necessitates that the outreach nurse has well-developed patient assessment skills, can make a professional judgement on the necessary action, and articulate a competent case for the course suggested. As a result of the challenges in performing safely and effectively in an outreach capacity, the outreach teams at Southampton University Hospitals Trust and Portsmouth NHS Hospitals have undertaken an introductory course to physical assessment skills.
Physical assessment skills As Rushforth et al. (1998) emphasise, within a United Kingdom context, physical assessment undertaken by nurses has historically been regarded as the recording of key vital signs including temperature, heart rate, blood pressure, and respiratory rate. Wider consultation of the North American literature reveals a broader definition in use including the auscultation of lungs and heart and palpation of the abdomen. Indeed, physical
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Table 1 Key physical assessment skills (adapted Jarvis 2000) Inspection Palpation Percussion Auscultation
Use of visual skills to gather information on a particular system, or the patient as a whole Application of touch to assess texture, temperature, moisture, organ location and size, swelling, vibration, pulsation, rigidity/spastisity, crepitation, masses and pain Taping of the skin with short, sharp strokes to assess underlying structures. Reflected sound depicts location, size and density of underlying organs Using the stethoscope to listen to sounds produced by the body
assessment skills have been located in the American and Canadian nursing syllabi since the 1970s (Bear 1995) with similar programmes more recently established within Australia (Wilson & Lillibridge 1995). Physical assessment has been defined as a systematic use of the skills of inspection, palpation, auscultation, and percussion (Bickley & Hoekelman 1999). Table 1 defines these key skill areas further. However, as highlighted by James and Reaby (1987), these skills are primarily confined within the practice of nursing to the recognition of ‘normal’ and deviations from this. The findings of empirical work undertaken in this area confirms that after completion of a physical assessment course, such skills are integrated into clinical practice (Sony 1992; Reaby & James 1990) with increased confidence in their use (Brown et al. 1987). Whilst the overall effect on patient management has not been explored, there has been a demonstrable improvement in decision making (Reaby 1990). However, caution must be exercised as much of the literature in this area uses small sample sizes and originates from North America and specifically focuses on nurse practitioner roles. These factors must be acknowledged when considering the transferability of the results.
The ‘introduction to physical assessment and history taking’ course The module that both authors undertook was offered by the School of Nursing and Midwifery at the University of Southampton. The course was offered as a 20 Credit Level 2 or 3 course comprising of 30 h of programmed study, 70 h independent study and 100 h practice. The module’s aim was to equip practitioners with an enhanced range of history taking and physical assessment skills. The
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systematic framework of inspection, palpation, percussion and auscultation was taught and then built into a more comprehensive patient assessment. The summative assessment for the module was through an OSCE (objective structured clinical evaluation) to assess practice, and a 2000 word assignment for those undertaking the module at Level 3. The module was offered to practitioners caring for patients/clients across the life span and in diverse clinical settings. In this way, the course cohort could consist of nurses working in acute medical admissions units, children’s recovery areas, mental health settings and community practitioners. The competencies gained during the module were not specifically related to patient diagnosis, but to detect normal from abnormal, thereby enhancing early detection and referral to appropriately skilled practitioners. The course was taught using a systems approach and underpinned by the theory base of applied anatomy and knowledge of key assessment techniques. Throughout the course a holistic perspective acknowledging wider psychological, emotional, and social influences was re-enforced. Patient privacy, dignity, confidentiality was also strongly emphasised through sessions on the legal, ethical and documentary aspects of patient assessment and history taking. The course was run over a 12-week period allowing application in practice and shared learning in groups sessions organised by the cohort between the formal taught sessions. The practical sessions required high tutor–student ratio. This ensured that students could work in small groups with tutors to have intensive support and coaching required to become proficient in the assessment techniques. These groups also needed sensitive handling to ensure students felt comfortable to act as models for each other to allow learning to occur on healthy volunteers. Being examined by
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Physical assessment skills: a developing dimension of clinical nursing practice
ones peers for this course was a salient lesson for all in reminding us of the embarrassment patients must feel sitting semi-naked awaiting examination by a clinician.
Patient case studies As the focus of this paper is on physical assessment skills, two case studies will now be presented to demonstrate the application of physical assessment skills into the critical care outreach practice. The two case studies chosen reflect not only two of the most common patient problems encountered by the authors within their outreach role but also focuses on the examination of two different anatomical systems and the resultant assessment techniques. In this section, the patient histories are introduced followed by specific details of the physical assessment undertaken. The rationale for the clinical decisions made are then explored. These case studies are not intended to reflect a comprehensive patient assessment. Therefore, whilst a wide range of clinical diagnostic tests were also used to successfully manage these patient situations, only the pertinent clinical assessment details will be referred to. Case presentation A Peter Brown aged 54, was an emergency admission to hospital with a 3 week history of lower abdominal pain, per rectum bleeding, anorexia and weight loss. He had previously been fit and well, with no relevant past medical history. He is a non-smoker. His social history is that of a postman who lives with his wife. Five days after admission, Mr Brown developed a strangulated right femoral hernia that was surgically reduced. Post-operatively he returned to the ward but within 2 days had developed an acute abdomen. An emergency laparotomy, total colectomy and end ileostomy was performed for a colitic colon with multiple perforations. Following this procedure Mr Brown was admitted to the ICU for management of intra-abdominal sepsis. His condition improved and within 24 h was successfully weaned from the ventilator and extubated. Due to a coagulopathy, an epidural
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had not been sited and he was discharged from ICU at 18:30 h with a morphine patient controlled analgesia (PCA) pump in situ. An outreach follow-up visit that night identified that Mr Brown had abdominal pain and did not appear to be using the PCA effectively. He was shown how to use the pump again and the nursing staff were advised to contact the surgical team for alternative or supplemental analgesia if his pain remained a problem. At 07:45 h the following morning Mr Brown was reviewed again by the outreach team. An update was obtained from the ward nurse caring for him on his condition. The nurse reported that his arterial oxygen saturations had dropped to 84% on 40% humidified oxygen so he had been commenced on 100% oxygen via a non-rebreathe mask. Patient assessment On approaching Mr Brown, I established that he was lying semi-recumbent, looked pale, appeared drowsy and had an oxygen non-rebreathe mask in situ. Mr Brown was responsive to voice but appeared confused and disorientated. When attempting to sit him up he complained of severe abdominal pain. Analgesia was given by encouraging the patient to use the PCA, he was then repositioned and supported with pillows. Having gained consent, a physical assessment was performed. The results of this are detailed in Fig. 1. Interpreting the physical assessment results On reviewing the results of the physical assessment, the findings indicated that Mr Brown was in respiratory distress/failure. Respiratory failure post operatively is noted to due to aspiration, bronchospasm, atelectasis, pneumonia, pulmonary embolus or pneumothorax (Yentis et al. 2000). Other causes may include cardiac failure or fluid overload (Burkitt & Quick 2000). His discharge handover from ICU and medical notes confirmed that he had been unwell and relatively immobile since his initial surgery 5 days previously. Following his second operation he had required intubation
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Fig. 1 Findings of Mr Brown’s physical assessment.
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and ventilation. Pain management had been problematic contributing to his inability to cough and deep breathe effectively. This can precipitate the risk of acquiring chest infection or atelectasis (Manley & Bellman 2000). On inspection, although Mr Brown was pale and perspiring, there were no signs of central cyanosis. This is normally evident when the arterial oxygen saturation is less than 85% (Smith 2000). There were no signs of chronic respiratory problems with no evidence of clubbing and a normal antero-posterior chest diameter ratio. The presence of tachypnoea, hyponoea, the use of accessory muscles and the inability to complete full sentences all indicated a compensatory increase in breathing that occur in moderate to severe respiratory failure (Mangione 2000). The irregular nature of Mr Brown’s respiratory pattern together with the asymmetrical movement of the left side of his chest was indicative of atelectasic collapse, pneumonia or pneumothorax (Jarvis 2000). On palpation there were no signs of chest tenderness or surgical emphysema. Palpation did further confirm the lag noted earlier on the left side of the chest wall. Vocal tactile fremitus was decreased in the left lung. This demonstrated that there was an obstruction in the transmission of vibrations generated by the larynx through the tracheobronchial tree to the chest wall. The causes of this include obstruction of the bronchus with a mucous plug leading to atelectasis, and fluid or air in the pleural space (Mangione 2000). Despite the above findings, assessment of the trachea was unremarkable, and the trachea was in a midline position. However as Smith (2000) suggests, in severe atelectasis there may be tracheal alignment towards the affected side. Further abnormalities to the left lung were identified through percussion. The right lung was predominately resonant. The left lung was dull to percussion as evidenced in both collapse and consolidation. There was no evidence of hyper-resonance indicative of a pneumothorax. Evidence of a collapsed lung was further increased on auscultation. In the right lung, normal vesicular breath sounds could be identified with crackles in the right base clearing with coughing and therefore suggestive of secretions. Breath sounds to the left lung were severely diminished with no
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adventitious sounds. There was no evidence of bronchial breathing that may have been heard if consolidation due to pneumonia was present (Jarvis 2000). Further assessment suggested that fluid overload was not a causative factor of his respiratory distress. Although tachycardic with a reduced blood pressure, Mr Brown’s tongue was dry and coated, his capillary refill slightly prolonged, CVP + 10 cm H20 and his urine output adequate but concentrated in appearance. Normal S1 and S2 heart sounds were identified but there was no evidence of S3 or S4 as heard in volume overload or decreased cardiac compliance. Compounded by severe pain and the ineffective use of the PCA, Mr Brown was unable to deep breathe, cough or move effectively. These factors placed him at an increased risk of developing atelectasis (Manley & Bellman 2000), which Dunn (1998) has noted to usually occur within 48 h of surgery. The conclusion from the respiratory assessment was therefore highly suspicious that his respiratory inadequacy was due to a collapsed left lung and atelectasis. Outcome for the patient Mr Brown’s management was discussed with the surgical, nursing, physiotherapy and pain teams. A chest X-ray confirmed a collapse of the left lung. Arterial blood gases were within normal limits on 100% oxygen. Alternative analgesia was prescribed by the surgical team and administered with effect. Physiotherapy management consisted of regular chest physiotherapy, saline nebulisers and Bird therapy. Intravenous fluids were increased to aid hydration. Advice was given to nursing staff regarding positioning of the patient, the need for regular deep breathing exercises, maintenance of adequate pain control and the need for regular observations, including continuous arterial oxygen saturation monitoring. Following increased pain relief and intensive physiotherapy, Mr Brown’s condition had improved by that evening. His respiratory rate was 17 breaths per min, oxygen saturations were 96–98% on 60% humidified oxygen and chest expansion and air entry on
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the left side had improved. Mr Brown was able to deep breathe and cough effectively with encouragement. Mr Brown’s recovery was slow and he remained hospitalised for a further 3 weeks. A total of 15 outreach visits were required. Once discharged home he continued to progress and at his outpatient’s appointment 2 months later, was fit and well.
explaining why I was there, I held her hand. I noted her to be cool peripherally. On asking how she was feeling in herself, she was almost euphoric and said that she had never felt better and had no pain. However she felt very thirsty. After asking Mrs Smith’s consent to examine her, she laid comfortably in the bed. The relevant assessment details are listed in Fig. 2. Interpreting the physical assessment results
Case presentation B Gladys Smith, aged 78, was initially admitted to the hospital as an elective admission suffering from gallstones. She was an active, independent, widowed lady with a close family who lived nearby. Mrs Smith was booked in for a laparoscopic cholecystectomy. Her surgery went ahead with no other past medical history except a note of atrial fibrillation that was well-controlled on oral digoxin. The surgery was documented as uneventful. However, her post-operative progress was slow and after further complaints of abdominal pain and discomfort, Mrs Smith returned to theatre during her fifth post-operative day for a laparotomy and repair of small bowel fistula. The nursing staff called the outreach team at 20:00 h the day following her small bowel fistula repair. They were concerned that Mrs Smith’s urine output had been ‘poor all day’ and her blood pressure was low (90 systolic) despite a 250 ml bolus of Gelofusine that had been administered that afternoon. It was reported that Mrs Smith had an epidural in situ and that an anaesthetist had administered a ‘bolus’ from her epidural syringe 2 h previously. The nursing staff had contacted the senior house officer who was busy in the Emergency Department and had given a verbal order for 20 mg of intravenous Frusemide. The ward staff were asking the outreach team for support as they were ‘unhappy’ with the order for diuretic but felt unable to challenge it. Patient assessment After talking with the ward nurse to clarify how outreach could help with this situation, I went with the ward nurse to examine Mrs Smith. On approaching Mrs Smith, she was sleeping but rousable. When introducing myself and
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In reviewing the key results of the physical assessment, the findings indicated that Mrs Smith was hypovolaemic. There could have been several causative factors for this. Many patients presenting with acute illness or for emergency surgery have a degree of hypovolaemia (Yentis et al. 2000). This may result from a reduction in extracellular and/or intracellular fluid as a result of dehydration, third space losses (e.g. surgery) or evaporative losses (e.g. peri-operatively), or from relative hypovolaemia due to epidural analgesia being administered. As Mrs Smith was sleepy, a substantial degree of her medical history was elicited from the nursing staff and medical notes. These revealed that due to the course of Mrs Smith’s problems and her two visits to theatre, there was an indication that she could be dehydrated. In addition, the nurse reported that she had recently received a top-up of her epidural analgesia from the anaesthetic staff. This can cause hypotension, which can be exacerbated in the presence of existing hypovolaemia (Stillwell 1996). It was clear that there had not been any excessive fluid losses from the surgical wounds or from the naso-gatric tube. However, the nature of the bowel sounds indicated a high suspicion of paralytic ileus (Metheny 1987), understandable considering Mrs Smith’s clinical history and treatment. However, this could have caused further third-space fluid shifts. Loss of blood during or after surgery was not indicated due to normal haemoglobin result. Mrs Smith’s assessment demonstrated that there was a reduction in cardiac output. Using standard nursing observations this was clearly illustrated. Mrs Smith was hypotensive at 85/40 mmHg. The medical notes revealed that previous blood pressure measurements were
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Physical assessment skills: a developing dimension of clinical nursing practice
Fig. 2 Findings of Mrs Smith’s physical assessment.
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165/115. Evidence of reduced cardiac function was further indicated by her cool and dusky peripheries and prolonged capillary refill. The poor volume radial pulse is also indicative of decreased stroke volumes. Mrs Smith had a low jugular venous pressure (JVP). Whilst acknowledging that technically ‘pressure’ can only be read with an invasive monitoring device, the term JVP is used here to indicate the height of the visualised pulsation or waveform of the jugular venous pulse. At 45◦ the JVP was not observable. It was only on posturing Mrs Smith at an angle of 30◦ that a JVP of 4 cm was observable. Mangione (2000) has observed that in patients with very low JVP the normal reading taken with the patient at a 45◦ angle may not distend the veins sufficiently to yield a reading. This was the clinical situation with Mrs Smith. It was only in reclining Mrs Smith to a 30◦ angle that the JVP became visible. Inspection of the waveform of the JVP was aided by the use of tangential lighting. This was achieved by shining a bedside light at an angle over Mrs Smith’s neck. Inspection of the JVP waveform by an experienced clinician would have revealed an absent A wave. The A wave is the first and dominant positive wave and is produced by right atrial contraction. However, inspection of the 12 lead electrocardiogram and the prescience of an irregularly irregular radial pulse confirmed that Mrs Smith was in atrial fibrillation. The decreased JVP therefore reflected a low CVP which itself is indicative of depleted intravascular volume and was confirmed by the presence of a dry, coated tongue and a reduction in skin turgour. The reduced urine output (less than 0.5 ml/kg/h) testified that there was an inadequate blood flow to perfuse the vital organs of the kidneys. The conclusion of the cardiovascular assessment was that, apart from her atrial fibrillation, Mrs Smith had no indication of cardiac disease. The absence of xanthelasmas, a yellow lipid plaque on the eyelids, indicated that there was no obvious evidence of hyperlipidaemia with its predisposition to atherosclerosis. Neither clubbing of the fingers nor peripheral oedema was present. The presence of arcus senilis, a whitish opaque ring surrounding the iris is a normal finding in
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the elderly, and therefore not itself indicative of a cardiac problem. There were no apical heave or thrills palpated, indicating that fluid overload in the left ventricle or major vessels were not present. Auscultating the heart with the diaphragm of the stethoscope, revealed that Mrs Smith had normal S1 and S2 heart sounds. The bell was used to pick up any lower pitched heart sounds including the sounds of S3 and S4. There were no added heart sounds or cardiac murmurs on auscultation. If an S3 had been heard, this would have indicated decreased myocardial contractility, myocardial failure or volume overload of a ventricle. An S4 heard would indicate decreased compliance of the ventricular myocardium (Bickley & Hoekelman 1999). The concerns regarding fluid overload were further diminished through using respiratory assessment. Mrs Smith’s respiratory rate was only 10/min, although it was acknowledged that with such a high epidural block (at nipple level) some respiratory depression may have been present. However, Mrs Smith was not using her intercostal or sternomastoid accessory muscles to breathe. The lung fields were resonant on percussion demonstrating normal aerated lung tissue (Bickley & Hoekelman 1999). Vesicular sounds were heard over all zones of Mrs Smith’s lungs indicating normal breath sounds. The only adventitious or added breath sounds were crackles heard at the lung bases. However, these were present in the dependent portions of the lungs, and cleared after coughing. This was suggestive of being caused by secretions and therefore was to be expected after a prolonged period of recumbency. Despite being in a positive 3 l fluid balance over the past 48 h, concern over her age, and a history of atrial fibrillation, it was clear that in the absence of assessment data indicating cardiac failure, Mrs Smith was therefore hypovolaemic. Outcome for the patient Mrs Smith’s continuing management was discussed with both medical and nursing staff on the ward. The key management areas reviewed were related to fluid and pain
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Physical assessment skills: a developing dimension of clinical nursing practice
management, education on monitoring the patient in atrial fibrillation, the need for epidural observations, and the encouragement of posturing and deep breathing exercises. Two hours after receiving 250 ml of Gelofusin and an increase in her hourly fluids, Mrs Smith condition had stabilised. Continuing on the oxygen, her respiratory rate was 17/min with good respiratory effort and ability to deep breathe and cough. Chest auscultation remained clear with normal vesicular sounds. Her blood pressure was maintained at 135/85 with a heart rate of 89/min. She remained in atrial fibrillation. Her urine output increased to 50 ml/h. Mrs Smith was alert and oriented in herself. She had a Glasgow coma scale rating of 15 and was painfree. Her epidural remained at 6 ml/h with a satisfactory level of block. After several further visits requiring no direct intervention from outreach Mrs Smith was discharged from outreach care and continued to have an uneventful recovery. She was discharged 2 weeks after emergency surgery to a convalescence ward in a local hospital where her family continued to visit her.
Clinical issues raised The clinical problems explored in these case studies not only demonstrate how physical assessment skills can be used by the outreach team to support patient management, but also reveal the complex ward situations that are encountered. This indicates that there continues to be organisational issues in managing medical workload, medical and nursing team working within both ward and critical care areas. As highlighted by the first case study, there is a need for ICU to ensure pain relief is effectively established prior to transfer and that both patients and staff are familiar with the pain relief methods being used. This case also enforces the need for timely and accurate performance of ward observations and the importance of action on abnormal recordings. As evidenced by the second case presented, an epidural bolus was given to an already hypotensive patient. There is therefore also a need for outreach teams to challenge our intensive care colleagues about safe clinical practices.
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The two cases presented highlight how outreach have an ICU follow-up role and provide support for the sick ward patient. In both situations, the need to be proactive in patient care is clear. This requires all to be prepared to work within clinical teams and address issues in patient management; all must take responsibility in resolving patient management issues. The outreach role is therefore not just confined to patient management issues but also support all ward based practitioners in caring for the sick ward patient. Finally, it is equally imperative that in this new area of critical care practice, outreach nurses can identify the limits of their own safe practice and know when to safely intervene, and when to seek the expert advice and assistance of other clinical colleagues.
Conclusion Nursing has been challenged to respond and adapt to the current health care changes. This can only be achieved if nursing practice is further developed to meet a patient needs-led service (Department of Health 1999, 2000a, 2000b, 2001). It is clear that new skills and knowledge will need to be embraced by nurses to respond pro-actively to such a changing culture. It is not the first time in nursing’s history that the acquisition of new skills has been called for. The undertaking of cardiac monitoring and starting intravenous infusions has been shown to dramatically change the shape of nursing practice (Shortridge et al. 1977). Critical care nurses are once again being asked to consider changes in nursing practice to ensure that patient care is delivered in a safe and timely way (Department of Health 2001). It has been argued that teaching nurses physical assessment skills can make a significant contribution to the quality of care delivery (Rushforth et al. 1998) and develop a stronger sense of collegiality with other clinicians (Brown et al. 1987). With nurses perceived as a surveillance system for early detection of adverse occurrences (Fontaine 2001), physical assessment skills can enable a more accurate appraisal of patient change (Bear 1995) and thereby improve the patient experience during their critical illness.
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The central tenet of any role development, such as the use of physical assessment skills, is the need to deliver a non-fragmented patient-focused service. However, the most profound challenge rests with the nursing profession in its ability to determine role boundaries to benefit and safeguard the patient, but without a fundamental shift in the nature of nursing. It is the clarification and re-definition of the position of nursing in using such physical assessment skills that may be most crucial. References Bear EM 1995 Advanced practice nurses: how did we get here anyway? Advanced Practice Nursing Quarterly 1(11): 10–14 Bickley LS, Hoekelman RA 1999 Physical Examination and History Taking, 7th ed. Lippincott, Philadelphia Brown MC, Brown JD, Bayer MM 1987 Changing nursing practice through continuing education in physical assessment: perceived barriers to implementation. Journal of Continuing Education in Nursing 18(4): 111–115 Burkitt H, Quick C 2000 Essential Surgery: Problems, Diagnosis and Management, 3rd ed. Churchill Livingstone, Edinburgh Department of Health 1993 Hospital Doctors: Training for the Future. Report on the working group of specialist medical training. Department of Health, London Department of Health 1999 Making a Difference. Strengthening the Nursing, Midwives and Health Visitors Contribution to Health and Health Care. Department of Health, London Department of Health 2000a The NHS Plan. Department of Health, London Department of Health 2000b Comprehensive Critical Care Review: A Review of Adult Critical Care Services. Department of Health, London Department of Health 2001 The Nursing Contribution to the Provision of Comprehensive Critical Care for Adults: A Strategic Programme of Action. Department of Health, London Dunn DC 1998 Dunn’s Surgical Diagnosis and Management. A Guide to General Surgical Care, 3rd ed. Blackwell Science, Oxford Fontaine D 2001 World shortage hits critical care. UKCC— News Tuesday, 30 October, 2001, www.ukcc.org.uk Hunt G, Wainwright P 1994 Expanding the Role of the Nurse: The Scope of Professional Practice. Blackwell Scientific, Oxford James J, Reaby L 1987 Physical assessment skills for RNs. Australia Nursing Journal 17(1): 39–41
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